Anxiety: identification and management

Key points

• For all children, consider whether anxiety is contributing to the presentation.
• Psychological therapy should be the first-line and ongoing treatment; CBT is first line for children aged 8-18 with mild to moderate symptoms.
• Medication is not first line except in exceptional circumstances and should be combined with ongoing psychological therapy.
• SSRIs are the first-line medication, started at a low dose and titrated slowly; in Australia they are prescribed off label in children.
• No investigations are required unless an alternative diagnosis is being considered.

Overview

This Royal Children's Hospital Melbourne guideline covers the identification and management of anxiety in children. Anxiety disorders are among the most common mental health conditions in children and differ from a normal stress response by their intensity, duration and impact on daily function. Management combines psychoeducation, psychological therapy and, in selected cases, medication, with patient-centred care and shared decisions.

Assessment

Presentations vary with age and developmental stage and may include avoiding everyday situations such as school, social events, sport, eating or sleeping, frequent physical complaints such as tummy aches and headaches, sudden emotional outbursts or meltdowns, sleep difficulty, appetite changes, frequent reassurance seeking, poor concentration, and overplanning or overthinking. Symptoms are checked against DSM-5 or ICD-11 criteria. Risk factors include other mental health conditions, neurodevelopmental disorders such as autism or ADHD, chronic illness, sensory impairment, gender-related concerns, trauma, a family history of anxiety, depression, OCD or substance use disorders, and substance misuse. Examination includes a baseline physical exam with cardiac exam, blood pressure, heart rate and growth parameters, with targeted examination to exclude mimics such as hyperthyroidism. Screening tools such as the Spence Children's Anxiety Scale, SCARED or the Social Phobia Inventory must be supplemented by clinical interview and observation.

Psychoeducation and psychological therapy

Treatment discussion begins with psychoeducation about symptoms and perpetuating factors, effects on the family and quality of life, and possible negative effects of a diagnosis such as stigma. CBT is recommended as first-line treatment for children aged 8-18 with mild to moderate symptoms before medication is considered; evidence-informed internet CBT (for example BRAVE or Cool Kids) can be used from age 8. Play therapy could be considered for children under 8, those with procedural anxiety or medical trauma, or those under 12 who may struggle with CBT; acceptance and commitment therapy could be used at 12-18 years, particularly with chronic health conditions.

Medication

Medication is best started by a clinician experienced in paediatric psychotropic prescribing and may be added to therapy when anxiety is too severe for meaningful engagement, markedly limits school attendance, carries a moderate or greater risk of deliberate self-harm (medication may not reduce this risk and may increase agitation initially), or poses a significant risk to family wellbeing. SSRIs are first line; fluoxetine and escitalopram are sensible choices as they are FDA approved for depressive episodes. Example patterns: fluoxetine 5-10 mg start, typical dose 20-40 mg; sertraline 12.5-25 mg, typical 50-100 mg; escitalopram 5 mg, typical 10-20 mg. Benefit takes several weeks. Adverse effects include nausea, appetite loss, agitation, insomnia, headache and activation syndrome; caution is advised with ADHD or high arousal, a family history of bipolar disorder, or younger age. Antipsychotics, alpha-2 agonists, atomoxetine, reboxetine and tricyclic antidepressants are not recommended for anxiety disorders in isolation.

Follow-up and referral

Rating scales such as RCADS should be used throughout treatment; on starting medication, response and adverse effects are reviewed every 2 weeks. If tolerated doses are ineffective after a reasonable trial (for example 8 weeks), cessation and change are considered, first to another SSRI; SSRIs are tapered gradually. Consultation with a child and adolescent mental health specialist is advised for coexisting mental health problems or significant risk.

Frequently asked questions

What is the first treatment for anxiety in children?

Psychoeducation followed by psychological therapy; CBT is first line for children aged 8-18 with mild to moderate symptoms.

When can medication be used?

Only in exceptional circumstances, together with ongoing psychological therapy, for example when anxiety is too severe to engage in therapy or severely limits school attendance.

Are blood tests needed?

No investigations are required unless an alternative diagnosis is being considered.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Anxiety: identification and management. Last updated April 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). This summary was prepared by Medpresso from the original guideline and is not a substitute for the full text or for medical advice.